Health Insurance Coverage Along the US-Mexico Border:

An Overview

Juan R. Albertorio-Díaz, MAJuan R. Albertorio-Díaz, MA&&

Jill Marsteller, Ph.D. Jill Marsteller, Ph.D.

National Center for Health StatisticsNational Center for Health StatisticsCenter for Disease Control and PreventionCenter for Disease Control and Prevention

Objectives

Upon completion of this presentation : Upon completion of this presentation : Quantify the lack of health insurance Quantify the lack of health insurance

along the US-MX Border by ethnicityalong the US-MX Border by ethnicityEvaluate access to health care by Evaluate access to health care by

ethnicity and insurance statusethnicity and insurance status

What to do?

Tailor a Healthy People program that Tailor a Healthy People program that addresses the health needs on the Borderaddresses the health needs on the Border

Healthy Border 2010 Healthy Border 2010 ProgramProgram

Healthy Border 2010 common topic areas

Topic AreaTopic Area Common TopicsCommon Topics

Access to Health CareAccess to Health Care Ensure access to primary care or basic health care servicesEnsure access to primary care or basic health care services

CancerCancer Reduce breast & cervical cancer mortalityReduce breast & cervical cancer mortality

DiabetesDiabetes Reduce diabetes mortality rate & need of hospitalizationReduce diabetes mortality rate & need of hospitalization

Environmental HealthEnvironmental Health Improve household access to sewage Improve household access to sewage Reduce hospital admission for acute pesticide poisoning Reduce hospital admission for acute pesticide poisoning

HIV/AIDSHIV/AIDS Reduce incidence of HIVReduce incidence of HIV

Immunizations & Infectious Immunizations & Infectious DiseaseDisease

Expand immunization coverage Expand immunization coverage Reduce incidence of Hepatitis & TBReduce incidence of Hepatitis & TB

Injury PreventionInjury Prevention Reduce mortality related to motor vehicle crashes; Reduce mortality related to motor vehicle crashes; Reduce childhood mortality due to injuriesReduce childhood mortality due to injuries

Maternal Infant & Child Maternal Infant & Child HealthHealth

Reduce infant mortality-due to congenital defects Reduce infant mortality-due to congenital defects Improve prenatal care Improve prenatal care Reduce teenage pregnancy rates Reduce teenage pregnancy rates

Mental HealthMental Health Reduce suicide mortalityReduce suicide mortality

Oral HealthOral Health Improve access to oral health careImprove access to oral health care

Respiratory DiseaseRespiratory Disease Reduce asthma hospitalization rateReduce asthma hospitalization rate

Timeline: US questionnaire and survey design, Behavioral Risk Factor Surveillance Survey (BRFSS)

Border Health Behavioral Risk Factor Survey (BHBRFS)Border Health Behavioral Risk Factor Survey (BHBRFS)

Feb. 2004 – First meeting in El Paso Feb. 2004 – First draft of questionnaire, based on BRFS March 2004 – Draft funding agreement and draft #2 of questionnaire April-June 2004 – Multiple drafts of questionnaire July-Sept 2004 – Texas border survey April 2005 – Questionnaire revision based on pilot survey results

Began with literal translation of US questionnaire Questionnaire modified using cognitive interviewing techniques:

Cognitive interviewing workshop held in El Paso, July 2005 Participants from US and Mexico

Cognitive techniques applied to sample of respondents in Juarez Led to many changes/improvements in Spanish-language questionnaire Spanish questionnaire will be used in US as well

Methodology Merged 4 years of the Inhouse National Health Interview Merged 4 years of the Inhouse National Health Interview

Survey (2000-2003)Survey (2000-2003) Analysis limited to adult (18+)Analysis limited to adult (18+) Ethnicity (Hispanic vs. Non Hispanic)Ethnicity (Hispanic vs. Non Hispanic) Uninsured Status:Uninsured Status:

Did not have any private health insurance, Medicare, Did not have any private health insurance, Medicare, Medicaid, SCHIP, State sponsored or other government Medicaid, SCHIP, State sponsored or other government sponsored health plan, or military plan at the time of the sponsored health plan, or military plan at the time of the interview. interview.

Had only Indian Health Service coverage or had only a Had only Indian Health Service coverage or had only a private plan that paid for one type of service such as private plan that paid for one type of service such as accident or dental care. accident or dental care.

Border Vs. Non Border counties, 4 Border states combined and Border Vs. Non Border counties, 4 Border states combined and the U.S.the U.S.

Use SPSS 13.0 Complex sample moduleUse SPSS 13.0 Complex sample module

Border adult population are more likely to not have health insurance at the time of the interview :2000-2003

Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

* Stat significance at 95%* Stat significance at 95%

14.7

22.9*

0

5

10

15

20

25

30

US Border

Percentage

Hispanics at the Border are more likely to not have health insurance coverage than Hispanics nationally: 2000-2003

Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Percent of the Population Without Health Insurance Coverage at the Time of the Interview (Current Lack of Health Insurance Coverage)

by Ethnic Groups: 2000-2003

12.0 12.0

32.7

38.2*

0

10

20

30

40

50

NONHISPANIC

HISPANIC NONHISPANIC

HISPANIC

US Border

Percentage

Hispanics at the Border are more likely to not have health insurance coverage than Hispanics in all region examined: 2000-2003

Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

14.7

20.6 20.1

32.7 33.4

38.2*

32.3

13.412.0

13.2

22.9

12.0

0

5

10

15

20

25

30

35

40

45

Total NonHispanic

Hispanic Total NonHispanic

Hispanic Total NonHispanic

Hispanic Total NonHispanic

Hispanic

US Border StatesCombined

Border Non Border

Percentage

Hispanics are more likely to not have a usual place to receive health care when they are sick or need advice about their own health: 2000-2003

Verbatim : “Is there any place that you USUALLY go when you are sick or need advice about your health?”Verbatim : “Is there any place that you USUALLY go when you are sick or need advice about your health?”No response.No response.Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Hispanics are less likely to have seen/talked to a doctor in the past year: 2000-2003

Verbatim : “DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care Verbatim : “DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own health? A general doctor who treats a variety of illness ( a doctor in general practice,providers about your own health? A general doctor who treats a variety of illness ( a doctor in general practice,Family medicine, or internal medicine).Family medicine, or internal medicine).Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Hispanic are more likely to have not seen/talked to a dentist in more than a year: 2000-2003

Verbatim : “About how long last it been since you last saw a dentist?” One year benchmark.Verbatim : “About how long last it been since you last saw a dentist?” One year benchmark.Include all type of dentist, such as orthodontists, oral surgeons, and all other dental specialist, as well as Include all type of dentist, such as orthodontists, oral surgeons, and all other dental specialist, as well as dental hygienists.dental hygienists.Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Hispanics are less likely to have seen/talked to a mental health professional in the past 12 months: 2000-2003

Verbatim : “DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care Verbatim : “DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own health? A mental health professional such as psychiatrist, psychologist, psychiatricproviders about your own health? A mental health professional such as psychiatrist, psychologist, psychiatricNurse, or clinical social worker?Nurse, or clinical social worker?Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Verbatim : “During the last 12 months, was there any time when you need it medical careVerbatim : “During the last 12 months, was there any time when you need it medical care but you did not get it because you could not afford it?but you did not get it because you could not afford it?Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Hispanics are more likely to self-report unmet medical need due to cost: 2000-2003

4.75.4

4.3

6.0

0

5

10

US Border

Percentage

NON HISPANIC

HISPANIC

Uninsured adult population is more likely to not be able to afford dental care for the past 12 months: 2000-2003

Verbatim : “DURING THE PAST 12 MONTHS was there any time when you needed any of the following Verbatim : “DURING THE PAST 12 MONTHS was there any time when you needed any of the following (dental care including check-ups), but did not get it because you could not afford it?(dental care including check-ups), but did not get it because you could not afford it?Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Hispanics at the Border are less likely to have received mental care/counsel services due to the cost even when they needed it: 2000-2003

Verbatim : “DURING THE PAST 12 MONTHS was there any time when you needed mental health Verbatim : “DURING THE PAST 12 MONTHS was there any time when you needed mental health counseling, but did not get it because you could not afford it?counseling, but did not get it because you could not afford it?Source: Inhouse National Health Interview Survey, 2000-2003Source: Inhouse National Health Interview Survey, 2000-2003

Table: Significant logistic regression results: odds ratio estimates for the Border population < 64 Years of age: Uninsured status

CharacteristicsCharacteristics LevelLevel Change in oddsChange in odds95% Wald95% Wald

Confidence IntervalsConfidence Intervals

Sex (Comparison is Female)Sex (Comparison is Female) MaleMale 1.401.40 1.121.12 1.741.74

Ethnicity (Comparison is Non-Hispanic)Ethnicity (Comparison is Non-Hispanic) HispanicHispanic 2.082.08 1.481.48 2.912.91

Residence (Comparison is Urban)Residence (Comparison is Urban) RuralRural 1.611.61 1.151.15 2.252.25

Marital Status (Comparison: Separate, Divorce, & Married)Marital Status (Comparison: Separate, Divorce, & Married) SingleSingle 1.441.44 1.101.10 1.891.89

Citizenship (Comparison is Citizen)Citizenship (Comparison is Citizen)Not a Not a citizenshipcitizenship

2.672.67 2.252.25 3.163.16

Income (Comparison is not poor)Income (Comparison is not poor)Poor & Near Poor & Near PoorPoor

3.653.65 3.043.04 4.384.38

RR22= .352 (Nagelkerke)= .352 (Nagelkerke)

Non-significant effects controlling for age, family size, employment status, and health statusNon-significant effects controlling for age, family size, employment status, and health status

Data Source: 2000-2003 Inhourse National Health Interview SurveyData Source: 2000-2003 Inhourse National Health Interview Survey

RemarksPreliminary data shows:Preliminary data shows:

Within US-Mexico Border counties, 22.9% of people were uninsured and 86.9% of these had Within US-Mexico Border counties, 22.9% of people were uninsured and 86.9% of these had lacked coverage for a year or more. lacked coverage for a year or more.

At all geographic levels, uninsurance was considerably higher for Hispanics. The difference At all geographic levels, uninsurance was considerably higher for Hispanics. The difference between Hispanics and Non-Hispanics was larger in the Border counties than nationally. between Hispanics and Non-Hispanics was larger in the Border counties than nationally.

Lack of health insurance at the Border showed similar patterns as nationally.Lack of health insurance at the Border showed similar patterns as nationally. Ethnicity and health insurance status has a direct effect on the accessibility of health care Ethnicity and health insurance status has a direct effect on the accessibility of health care

services services NHIS is a effective tool for measure AHC along the BorderNHIS is a effective tool for measure AHC along the Border

Future research direction:Future research direction:

Perform further analysis of the concept of AHC using NHISPerform further analysis of the concept of AHC using NHIS Study the construct of AHC as a function of demographic variablesStudy the construct of AHC as a function of demographic variables Study economic burden of AHC at the Border. Study economic burden of AHC at the Border. Psychological distress co-occurring with limited AHCPsychological distress co-occurring with limited AHC

Explore other areas of research: asthma, diabetes, cancer incidenceExplore other areas of research: asthma, diabetes, cancer incidence Ethnographic studiesEthnographic studies

Limitations

Survey modeSurvey mode SampleSample

Convenience sampleConvenience sample

Comparison of CLHIC between NHIS and BRFSS by ethnicity

Thanks…

Sam Notzon, Ph.D.Sam Notzon, Ph.D. National Health Interview Survey StaffNational Health Interview Survey Staff

Robin Cohen, Ph.D. Robin Cohen, Ph.D. Viona BrownViona Brown Eve Powell-Griner, Ph.D.Eve Powell-Griner, Ph.D. Susan Jack Susan Jack

US-Mexico Border Health CommissionUS-Mexico Border Health Commission

United States-Mexico Border Health Commission Activities

•Healthy Border 2010Healthy Border 2010•Early Warning Infectious Diseases Early Warning Infectious Diseases Surveillance ProjectSurveillance Project• Border Models of ExcellenceBorder Models of Excellence•Binational Tuberculosis Case Binational Tuberculosis Case Management Pilot ProjectManagement Pilot Project• Border Health Information NetworkBorder Health Information Network•Promotoras, among others new Promotoras, among others new initiatives initiatives

http://www.borderhealth.org/http://www.borderhealth.org/

“An approximate answer to the right problem is worth a good deal more

than an exact answer to an approximate problem”

--J.W. Tukey

References

Desai J. State-based diabetes surveillance among minority populations Prev Chronic Dis [serial online] 2004 Apr . Available from : URL: http://www.cdc.gov/pcd/issues/2004/apr/03_0030.htm

Land G. Measuring 2010 national objectives and leading indicators at the state and local level. J Public Health Manag Prac 2002;8 (4):9-13.

Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in healthcare. Washington (DC): National Academies Press; 2003. 764 p.